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There is a notable difference in occupational injury rates in the two Scandinavian countries, Sweden and Denmark, with the latter having a 40% higher rate of fatal occupational injuries in the construction industry. This study explored differences in the vocational education and training (VET) systems between Sweden and Denmark that may be important for students' safety learning and practice during VET. In both countries, students participate in full-time education, and the curriculum includes school-based as well as company- based training. However, during company- based training Swedish students retain their student status, whereas Danish students are employed as apprentices. From a perspective of viewing safety as a social practice developed through interactions of different social and institutional bodies, the analysis points to this difference in employment status as important for their safety practices and also for the teachers' position to influence safety learning and practices during company-based training. An analysis of interview and survey data focusing on how VET students enact safety 'knowings' across learning sites, suggest how different forms of connectivity models in VET promote various forms of safety learning among students.

Background: People with musculoskeletal pain seek more healthcare than the general population, however little is known about the long-term effect on healthcare use. The aim of this study was to examine the consequences of number of musculoskeletal pain sites on long-term care-seeking and healthcare-related costs and explore how health anxiety influences this relationship., Methods: We conducted a Danish population-based longitudinal cohort study of 4883 participants combining self-reported survey data from 2008 with ten-year follow-up data from national health registers. Using a causal inference framework, we examined associations between number of pain sites (range 0-7)/level of health anxiety (high/low level) and face-to-face healthcare contacts/healthcare-related costs. Data were analyzed using negative binomial regression with generalized estimating equations. Regression models were adjusted for sex, age, duration of pain, level of education, comorbidity, personality traits, risk of depression, marital status, physical job exposure, and previous healthcare utilization., Results: For each additional pain site general healthcare contacts (Incidence Rate Ratio (IRR): 1.04 (95% CI: 1.03-1.05)), healthcare-related costs (IRR: 1.06 (95% CI: 1.03-1.08) and musculoskeletal healthcare contacts (IRR: 1.11 (95% CI:1.09-1.14) increased. Those with high levels of health anxiety at baseline had a slightly higher number of general healthcare contacts (IRR 1.06 (1.01-1.11), independent of number of pain sites. However, level of anxiety did not influence the effect of number of pain sites on any healthcare use or cost outcomes., Conclusions: We found evidence for a causal association between increasing number of pain sites and greater healthcare use and cost, and high levels of health anxiety did not increase the strength of this association. This suggests that number of pain sites could be a potential target for biopsychosocial interventions in order to reduce the need for future care-seeking., (© 2021. The Author(s).)

Background and aims Using a computer algorithm to quantify pain drawings could be useful, especially when large numbers of drawings need to be assessed. Whilst informal visual assessment of pain drawings can give clinicians a quick impression of the extent of pain and its location, formal quantification of pain drawings by computer for research purposes is not necessarily trivial. The current study compared seven different approaches to quantification in a large sample of clinical spinal pain drawings. Methods A large number (n = 55,720) of pain drawings were extracted from the SpineData database, a clinical registry of spinal pain patients in the Region of Southern Denmark. Drawings were analyzed both as pixel (raster) and vector based images, with different approaches based on the raw pain drawing, simple encircling polygons, convex-hull encircling polygons and discrete anatomical regions. Data were analyzed using principal component analysis, correlation and linear regression, as well as informal visual inspection of outlier pain drawings. Results Eighty-one percent of the variance could be explained by the first principal component, which we interpreted as the true score variance, i.e. the variance attributable to differences in pain area between individuals. The second principal component explained 10% of the variance and was loaded differentially by polygon-based methods and non-polygon-based methods. Correlations between the different approaches ranged from 0.66 to 1.00. Some approaches correlated so strongly as to be interchangeable, others tended to bias area estimates significantly. Visual inspection of outlier pain drawing indicated that when the different approaches to quantification yielded different results, characteristic patterns could be identified in the style and patterns of those pain drawings. Conclusions The different approaches reflected the same underlying construct (pain area), but could not be relied upon to produce the same area estimates and were affected by the interaction between drawing style and quantification approach. To some extend, the "correct" choice of quantification method is specific to and dictated by the style of each pain drawing. A differentiated approach is required in which the results of quantification and the drawing style are considered in combination. We provide suggestions for such differentiated approaches taking into account the nature of the drawing data (raster vs. vector) and the method of analysis (partly vs completely automated). Implications The chosen method of quantifying pain drawings in combination with the drawing style of the individual patient, can impact the resulting area estimate to a significant degree. These issues should be considered before undertaking computerized area estimation of pain drawings.

Background: Clinicians nominate the distribution of leg pain as being important in diagnosing nerve root involvement. This study aimed to identify: (i) common unisegmental radicular pain patterns and whether they were dermatomal, and (ii) whether these radicular pain patterns assisted clinician discrimination of the nerve root level involved., Methods: A cross-sectional diagnostic accuracy study of adult patients with radicular leg pain at a hospital in Denmark. All patients had positive neurological signs (average 2.8 signs - hypoalgesia, diminished reflexes, muscle weakness, positive Straight Leg Raise test).Part 1 (pain patterns) was a secondary analysis of baseline pain pattern data collected during a clinical trial. The pain charts of 93 patients with an MRI and clinically confirmed single-level disc herniation with nerve root compression were digitised and layered to form a composite picture of the radicular patterns for the L5 and S1 nerve roots, which were then compared to published dermatomes.In Part 2 (clinical utility) we prospectively measured the discriminative ability of the identified pain patterns. The accuracy was calculated of three groups of six clinicians at classifying the nerve root affected in a randomized sequence of 53 patients, when not shown, briefly shown or continuously shown the composite pain patterns. In each group were two chiropractors, two medical doctors and two physiotherapists., Results: There was a wide overlap in pain patterns from compromised L5 and S1 nerve roots but some distinguishing features. These pain patterns had approximately 50 to 80% overlap with published dermatomes. Clinicians were unable to determine with any accuracy above chance whether an individual pain drawing was from a person with a compromised L5 or S1 nerve root, and use of the composite pain drawings did not improve that accuracy., Conclusions: While pain distribution may be an indication of radiculopathy, pain patterns from L5 or S1 nerve root compression only approximated those of sensory dermatomes, and level-specific knowledge about radicular pain patterns did not assist clinicians' diagnostic accuracy of the nerve root impinged. These results indicate that, on their own, pain patterns provide very limited additional diagnostic information about which individual nerve root is affected., Competing Interests: Competing interestsThe authors have no competing interests to declare., (© The Author(s). 2019.)

Background: Magnetic resonance imaging (MRI) is used to identify spinal pathoanatomy in people with persistent low back pain. However, the clinical relevance of spinal degenerative MRI findings remains uncertain. Although multiple MRI findings are almost always present at the same time, research into the association with clinical outcomes (such as pain) has predominantly focused on individual MRI findings. This study aimed to: (i) investigate how multiple MRI lumbar spine findings cluster together within two different samples of patients with low back pain, (ii) classify these clusters into hypothetical pathways of degeneration based on scientific knowledge of disco-vertebral degeneration, and (iii) compare these clusters and degenerative pathways between samples., Methods: We performed a secondary cross-sectional analysis on two dissimilar MRI samples collected in a hospital department: (1) data from the spinal MRI reports of 4,162 low back pain patients and (2) data from an MRI research protocol of 631 low back pain patients. Latent Class Analysis was used in both samples to cluster MRI findings from lumbar motion segments. Using content analysis, each cluster was then categorised into hypothetical pathways of degeneration., Results: Six clusters of MRI findings were identified in each of the two samples. The content of the clusters in the two samples displayed some differences but had the same overall pattern of MRI findings. Although the hypothetical degenerative pathways identified in the two samples were not identical, the overall pattern of increasing degeneration within the pathways was the same., Conclusions: It was expected that different clusters could emerge from different samples, however, when organised into hypothetical pathways of degeneration, the overall pattern of increasing degeneration was similar and biologically plausible. This evidence of reproducibility suggests that Latent Class Analysis may provide a new approach to investigating the relationship between MRI findings and clinically important characteristics such as pain and activity limitation.

Objectives: The aim of this study was to (1) test the concurrent validity of brief screening questions for 5 psychosocial constructs (anxiety, depression, social isolation, catastrophization, and fear of movement) and (2) translate into Danish and validate those screening questions., Materials and Methods: Data were collected from 5 cross-sectional samples (total n=1105) of people seeking care for low back pain in Australian primary care settings and a Danish secondary care hospital. The responses to English and Danish-translated versions of 1-item or 2-item screening questions were compared with those of validated full-length questionnaires., Results: Compared with anxiety, depression, and social isolation scores from full-length questionnaires, screening questionnaire responses demonstrated: a correlation of 0.62 to 0.83, overall accuracy of 78% to 91%, sensitivity of 70% to 82%, specificity of 75% to 95%, positive likelihood ratios of 3.3 to 13.9, and negative likelihood ratios of 0.21 to 0.33. For catastrophization and fear of movement, the results demonstrated: correlation of 0.89 to 0.95, overall accuracy of 88% to 93%, sensitivity of 78% to 88%, specificity of 91% to 96%, positive likelihood ratios of 9.5 to 20.8, and negative likelihood ratios of 0.13 to 0.23., Discussion: The concurrent validity of these screening questions was comparable to, or better than, alternate questions previously reported, and stable across age, sex, pain intensity, pain duration, and counties. On the basis of the observed likelihood ratios, all of the screening questions provided moderate or strong evidence to rule in or out an extreme score on each psychosocial construct. Given the ease of administration of these brief screening questions, their prognostic and treatment implications should be investigated.

Introduction: The predictive ability of the STarT Back Tool (SBT) in secondary care settings has not been investigated. The aim of this study was to determine the SBT's predictive ability in a Danish secondary care setting and compare this to a Danish primary care setting., Methods: Poor clinical outcome at 6 months (>30 points on a 0-100 Roland Morris Disability Scale) was calculated in secondary care (n = 960) and primary care (n = 172) cohorts. The cohorts were stratified into SBT subgroups and estimates of additional risk for poor outcome were calculated [relative risk (RR), unadjusted and adjusted odds ratios]. The discriminative ability was determined using the area under the curve statistic., Results: In secondary care 69.0 % and in primary care 40.2 % had poor outcome on activity limitation. Although significant, the predictive ability of the SBT in secondary care (medium-risk RR 1.5, high-risk RR 1.7) was not as strong as in primary care (medium-risk RR 2.3, high-risk RR 3.5). Adjusting for episode duration and pain intensity only changed the predictive ability marginally in secondary care. The discriminative ability of the SBT was similar in both cohorts despite differences in the predictive ability., Conclusion: The SBT had less predictive ability in a Danish secondary care setting compared to a Danish primary care setting for persistent activity limitation at 6 months follow-up. SBT-targeted treatment implications in secondary care were not investigated in this study.

Purpose: The STarT Back Tool (SBT) was recently translated into Danish and its concurrent validity described. This study tested the predictive validity of the Danish SBT., Methods: Danish primary care patients (n = 344) were compared to a UK cohort. SBT subgroup validity for predicting high activity limitation at 3 months' follow-up was assessed using descriptive proportions, relative risks, AUC and odds ratios., Results: The SBT had a statistically similar predictive ability in Danish primary care as in UK primary care. Unadjusted relative risks for poor clinical outcome on activity limitation in the Danish cohort were 2.4 (1.7-3.4) for the medium-risk subgroup and 2.8 (1.8-3.8) for the high-risk subgroup versus 3.1 (2.5-3.9) and 4.5 (3.6-5.6) for the UK cohort. Adjusting for confounders appeared to explain the lower predictive ability of the Danish high-risk group., Conclusions: The Danish SBT distinguished between low- and medium-risk subgroups with a similar predictive ability of the UK SBT. That distinction is useful information for informing patients about their expected prognosis and may help guiding clinicians' choice of treatment. However, cross-cultural differences in the SBT psychosocial subscale may reduce the predictive ability of the high-risk subgroup in Danish primary care.

Differences between the psychosocial risk factors of low back pain (LBP) patients in primary and secondary care are under-investigated. Similarly, differences in the psychosocial profile of people classified into STarT Back Screening Tool (SBT) subgroups in primary and secondary care settings have not been investigated. The aim of the study was to determine: (1) if movement-related fear, catastrophisation, anxiety and/or depression in LBP patients are different between primary and secondary care settings, and (2) if those differences are retained when stratified by SBT subgroup. This study was a cross-sectional comparison of LBP patients in Danish primary settings (405 general practitioner or physiotherapy patients) and a secondary care setting (311 outpatient spine centre patients). Psychosocial factors were measured with the Roland Morris Disability Questionnaire, the Tampa Scale of Kinesiophobia, the Coping Strategies Questionnaire (catastrophisation subscale), and the Hospital Anxiety and Depression Scale. There were significantly higher scores in secondary care for movement-related fear (1.3 points (95%CI .1-2.5) p = .030) and catastrophisation (2.0 (95%CI 1.0-3.0) p < .000), lower scores on anxiety (-1.0 (95%CI -1.0-2.0) p < .000) but no difference for depression. These differences in psychosocial scores were broadly retained when stratified by SBT subgroup. However, questionnaire-specific reported thresholds for important difference scores indicate the size of these differences between the care settings were unlikely to be clinically important from a patient perspective. Longitudinal studies are required to investigate the predictive ability of SBT in secondary care settings and whether treatment targeted to SBT subgroups is effective in secondary care., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: The STarT Back Screening Tool (STarT) is a nine-item patient self-report questionnaire that classifies low back pain patients into low, medium or high risk of poor prognosis. When assessed by GPs, these subgroups can be used to triage patients into different evidence-based treatment pathways. The objective of this study was to translate the English version of STarT into Danish (STarT-dk) and test its discriminative validity., Methods: Translation was performed using methods recommended by best practice translation guidelines. Psychometric validation of the discriminative ability was performed using the Area Under the Curve statistic. The Area Under the Curve was calculated for seven of the nine items where reference standards were available and compared with the original English version., Results: The linguistic translation required minor semantic and layout alterations. The response options were changed from "agree/disagree" to "yes/no" for four items. No patients reported item ambiguity using the final version. The Area Under the Curve ranged from 0.735 to 0.855 (CI95% 0.678-0.897) in a Danish cohort (n = 311) and 0.840 to 0.925 (CI95% 0.772-0.948) in the original English cohort (n = 500). On four items, the Area Under the Curve was statistically similar between the two cohorts but lower on three psychosocial sub-score items., Conclusions: The translation was linguistically accurate and the discriminative validity broadly similar, with some differences probably due to differences in severity between the cohorts and the Danish reference standard questionnaires not having been validated. Despite those differences, we believe the results show that the STarT-dk has sufficient patient acceptability and discriminative validity to be used in Denmark.

Study Design: Analysis of Roland Morris Disability Questionnaire (RMDQ) and Oswestry Disability Index (Oswestry) responses., Objective: To determine the prevalence of unanswered questions on the RMDQ23 (23-item RMDQ version) and Oswestry questionnaires. To determine whether managing RMDQ23 missing data using proportional recalculation is more accurate than simply ignoring missing data., Summary of Background Data: It is likely that the most common method for calculating an RMDQ sum score is to simply ignore any unanswered questions. In contrast, the raw sum score on the Oswestry is converted to a 0 to 100 scale, with the advantage of allowing missing data to be accommodated by proportional recalculation., Methods: The prevalence of unanswered RMDQ23 questions was measured in a research project and a routine care setting. The accuracy of the RMDQ23 proportional recalculation method was measured using 311 fully completed RMDQ23 and matching Oswestry questionnaire sets. Raw sum scores were calculated, and questions systematically dropped. At each stage, sum scores were converted to a score on a 0 to 100 scale and the error calculated. Wilcoxon Tests were used to compare the magnitude of the error scores., Results: The prevalence of people who did not answer one or more questions was 29.5% (RMDQ23) in routine care, and 13.9% (Oswestry) and 20.3% (RMDQ23) in a research project. Proportional recalculation was a more accurate method to calculate RMDQ sum scores than simply ignoring missing data, when two or more questions were unanswered., Conclusion: Because of less error when missing data are present, the most accurate method for expressing RMDQ sum scores collected using Yes/No answers is conversion to a 0 to 100 scale. This conversion method is (a) if all questions are answered or only one question is unanswered, multiply the raw sum score by 100 divided by the total number of questions, and (b) if two or more questions are unanswered, multiply the raw sum score by 100 divided by the number of answered questions.

Modic changes are of increasing interest, however their age and gender prevalence are not well described. To date, the associations between Modic changes and other common vertebral pathologies have only been described in small samples (n < 100). Our aim was, in a large dataset of people with low back pain, to (1) describe the prevalence of a range of spinal pathoanatomies, and (2) examine the association between Modic changes and stages of intervertebral disc (IVD) pathology. Common pathologies were coded from the lumbar spine MRIs from 4,233 consecutive people imaged while attending a publicly-funded secondary care outpatient facility in Denmark. Prevalence data were calculated by pathology and by vertebral level. Prevalence was also calculated by age and gender categories for Modic changes. The association between stages of IVD pathology (degeneration, bulge, herniation) and Modic changes at L4/5 and L5/S1 was expressed using prevalence ratios (PR) and 95% confidence intervals. The prevalence of Modic changes and IVD pathology were greater in L4/5 and L5/S1, compared with the upper lumbar spine. There was no significant gender difference in prevalence of Modic changes (p = 0.11). The prevalence of IVD disc pathology occurring concurrently with Modic changes ranged from 11.5 to 17.5% (Type 1), 8.5 to 12.7% (Type 2) and 17.1 to 25.6% (Type 1 and/or 2) while the prevalence occurring in the absence of Modic changes ranged from 0.5 to 6.3% (Type 1), 0.3 to 4.9 (Type 2), 0.8 to 9.7% (Type 1 and/or 2). The associated PR for IVD pathology occurring concurrently with Modic changes ranged from 1.8 to 29.2 (p < 0.05). The highest PR (29.2) was between degeneration and Modic changes, indicating that it is rare for Modic changes to occur without disc degeneration. Spinal pathoanatomy was common in this population, particularly IVD pathologies, and a consistent trend of a relatively greater prevalence in the lower lumbar spine was identified. Modic changes were more likely to be present among individuals with IVD pathology than without, which may implicate mechanical factors as being one aetiological pathway for Modic changes, although other hypotheses may equally explain this association.